We hypothesize, first, that health plans will develop advertising campaigns based on their perceptions of the incentives they face in local markets and, second, that the recent and growing emphasis on quality of care will lead to changes in advertising. The project addresses topic area 1, Provider and Health Plan Behavior, by exploring the nature of plan advertising over time, with an emphasis on the extent to which plans try to influence selection in health insurance markets through their advertising strategies. Since we also explore the degree to which plans use ads to exclude or discourage minority enrollment, our study is also related to topic area 3, Minority Access. While we cannot fully test the first hypothesis, we will be able to determine whether plan advertising from 1970-2000 follows patterns consistent with it by assessing whether plans increased their use of ads that might result in risk selections as the incentives to do so rose. To assess the second hypotheses, we will determine whether increasing purchaser interests in quality measurement to quality-based payment is associated with changes in plan advertising. We will also evaluate different methods of monitoring advertising. The specific aims of this project are: (1) to investigate the association between changes in the frequency of risk selection behaviors manifest in health plan newspaper advertising and changes in HMO market share in the same locations from 1970-2000; (2) to compare in each MSA the percentage of models in ads who are minorities to the local racial/ethnic mix and to assess whether competitiveness in local markets changes the probability that plans use minority models; (3) to calculate the rate of use in ads of themes and descriptions of benefits designed to attract healthy individuals/exclude the ill before and after the introduction of risk adjustment or as purchaser emphasis on quality increases in 2000-2004; and, finally, (4) to compare the frequency of risk selection behaviors in ads in major local newspapers to the frequency of such behaviors in ads in specialty local newspapers (e.g., Spanish-language papers) and on TV. The time period from which the ads are collected, the media studied, and the techniques of data analysis will vary with each specific aim. For aim 1, ads will come from the Duke Advertising Archives, while ads for aims 2 and 3 will be collected for this project by media monitoring companies. For all aims, we will employ content analysis to evaluate the message strategy of advertisements. We will create indices of risk selection behaviors to measure the extent to which plans use ads to select risk and record the frequency with which minorities are represented. These dependent variables will be regressed on local HMO market share for aim 1 and on more sophisticated measures of market competition for aims 2 and 3. We will control for the percentage of local populations who are minorities for aim 2 and for purchaser initiatives to risk adjust or improve quality for aim 3.